Congenital cyst adenomatoid malformation (CCAM) and intralobar sequestration: thoracoscopic left lower lobectomy

  • Abstract
    Congenital cystic adenomatoid malformation (CCAM) is the main indication for lobectomy in the pediatric patient. We present the case of a CCAM associated with intralobar pulmonary sequestration. A left lower thoracoscopic lobectomy is demonstrated.
  • 00'08" Introduction
    Congenital cystic adenomatoid malformation (CCAM) is the major indication of lobectomy in the pediatric patient. Here we present the case of a CCAM associated with intralobar pulmonary sequestration. A left lower lobectomy has been decided upon.
  • 00'23" Patient and trocar positioning
    The patient is placed in a right lateral decubitus with selective intubation. Carbon dioxide insufflation is used at a pressure of 5mm Hg. The optical system is introduced at the 5th intercostal space and the instruments are placed in a triangulation at the 3rd and 6th intercostal space. 3mm instruments are used here. Systemic vessels of the pulmonary sequestration originate from the thoracic aorta.
  • 01'22" Vascular approach
    We start with the dissection of these vessels and then we turn our attention to the oblique fissure, which is partially free. The camera introduced at the 5th intercostal space helps to obtain a direct view of the interlobar vessels. Here the vascular anatomy is ideally reconstructed in order to allow for selective dissection and division of the pulmonary arteries. Here the greater fissure is not totally free. In order to guarantee a perfect dissection, we first free this fissure using the Ligasure device that ensures a division with both pneumostasis and hemostasis.
  • 02'38" Lower lobar artery division
    Then the lower lobar artery is divided distal from the vessels of the upper lobe. The jaws of the Ligasure device should be perfectly clean in order to avoid any residual bleeding that may follow after the coagulation.
  • 03'10" Lower lobar bronchus dissection
    As a result, the bronchus is skeletonized. It is partially dissected in its anterior portion. We can identify the pulmonary vein posterior to the bronchus. Dissection of the bronchus should not induce its de-vascularization. Here we can clearly see the division of the lower lobar bronchus. We then turn our attention to the systemic vessels. There are several options from now onwards. However, in the present case, we prefer to use the Ligasure device since the length of the vessels allows for a safe coagulation. Indeed, if the vessels had been short, we would have opted for the use of either a ligature or clips. Here coagulation is sufficient to allow for a perfect hemostasis and the stump of vessels is long enough to resume the hemostasis or avoid a subdiaphragmatic retraction.
  • 04'52" Division of the triangular ligament
    The next step is the division of the triangular ligament of the lower lobe, which brings us directly to the pulmonary vein. The lower lobar vein is generally short. It should be dissected in a subadventitial position. Indeed, its perfect dissection is mandatory to give sufficient length.
  • 05'33" Division of the lower lobar vein
    Here we can clearly see the division of the lower lobar vein. This helps us to achieve a separate ligature. The ligature using Vicryl 3/0 concerns the proximal portion of each branch. The distal portion of the vein is coagulated and divided using the Ligasure device. The lower lobe is maintained suspended in order to obtain a good exposure of the region of the lobar vein. The bronchus is approached last. The same retraction forceps helps to lower the lobe to better expose the bronchus.
  • 07'01" Division of the lower lobar beonchus
    A vascular Endo-GIA linear stapler helps to staple and divide the lower lobar bronchus. The patency of this suture is controlled.
  • 07'20" Specimen extraction
    The specimen is extracted through the 12mm port. The extraction is easy to perform thanks to specific movements. We perform a lavage and drainage using 2 catheters placed anteriorly and inferiorly.
  • Related medias
    Congenital cystic adenomatoid malformation (CCAM) is the main indication for lobectomy in the pediatric patient. We present the case of a CCAM associated with intralobar pulmonary sequestration. A left lower thoracoscopic lobectomy is demonstrated.